NORTH YORK PULMONARY FUNCTION CENTER2 Champagne Drive, (Champagne Centre) Unit B21, Toronto, ON M3J 0K2
Tel: 416-636-6664 Fax: 416-636-8999
Pulmonary Function Testing Referral
Please turn over for patient instructions and directions to the clinic
PATIENT INFORMATION
Patient Name: ____________________________________________________________________________________________
Date of Birth: DAY____________________________ MONTH__________________________ YEAR _______________________
Address: ________________________________________________________________________________________________
________________________________________________________________________________________________________
Home Phone: ______________________________________ Work/ Cell Phone: _______________________________________
Health Card Number: __________________________________________ Version Code: ________________________________
SERVICES REQUIRED (Please Check All That Apply)
Respirology Consultation
Complete PFT (includes Pre/Post Bronchodilator Spirometry, Diffusion Capacity, Lung Volumes, Resting Oximetry)
Pre/Post Bronchodilator For Complete PFT & Pre/Post Bronchodilator, we administer Ventolin by default. If Atrovent is preferred, please tick off the box Spirometry
Resting Oximetry
Exercise Oximetry
Methacholine Challenge Test
Other: Please specify_____________________________________________________________
CLINICAL INFORMATION (Required)
Reason for Referral/ Other Clinical Information__________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Please Check all that Apply: Yes No Yes No
Suspected TB (Tuberculosis) Unstable Angina or MI/Heart Attack(Within 3 Months)
Hemoptysis (Physician’s discretion) Recent Surgery (within 4 wks)
REFERRING PHYSICIAN
(PRINT) Physician Name Physician Signature Date
Phone: _____________________________________________ Fax: _____________________________________________
Additional Copies to: ______________________________________________________________________________________
NORTH YORK PULMONARY FUNCTION CENTER
PATIENT PREPARATION SHEET – PULMONARY FUNCTION TESTING
1. For all general breathing tests you will be asked to perform a series of forced and relaxed breathing maneuvers. If
requested by your physician, a medication that may open your airways may be offered to you.
2. Your test may take up to 60 minutes.
3. Patients are asked NOT to take any breathing medication for 12 hours prior to the tests. If you are symptomatic and
need your breathing medication, take it and advise the Pulmonary Technician at your appointment. Take all your
other medications as usual.
4. Patients are not required to withhold medication for walking tests unless otherwise advised by the ordering physician.
5. If you have been booked for methacholine testing, please note that the test involves inhaling a preparation that may
irritate your lungs. You will be given a medication that will reverse the irritation within minutes. You will be asked to
sign a consent form prior to starting the test.
6. Please bring a list of all medication you are taking to your appointment.
7. Smoking should also be avoided for at least 4 hours prior to these tests.
8. If you are unable to keep your appointment, contact our office as soon as possible to rebook. We require 48 business
hours notice of cancellation so that another patient can be scheduled. Failure to provide 48 business hours
cancellation notice will result in a missed appointment fee of $100. This cancellation fee is not covered by OHIP.
9. To reschedule an appointment or inquire about any test you are booked for please contact our booking office at416-636-6664.
10. We are located at 2 Champagne Drive, Unit B21, Toronto, Ontario within the Champagne Centre. We are two blocks
West of Dufferin Street on the South side of Finch Avenue. Please enter through the East entrance located by the
parking lot.
11. Parking is free of charge.
YOUR TEST IS BOOKED FOR:
_______________________________________________
AT _____________________________________________
Finch Ave.
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